UK (Scotland) childhood influenza

vaccination programme –

experience from seasons 2013/14

and 2014/15

Dr Beatrix v. Wissmann

Epidemiologist

Respiratory Viral Team

Health Protection Scotland

2

Overview

• Scotland: Demography

• NHS Service Delivery Model

• Scottish Immunisation Programme (SIP)

• Extension of the SIP to offer Live Attenuated Intranasal Influenza Vaccination (LAIV) to children

• Uptake & determinants of uptake

• Impact (positive or negative) on the existing seasonal programme?

• Challenges overcome & lessons for next season

• Summary results across the UK for season 2014/15

2

854,000 of Scotland’s

5.3 million population

are children

Scotland: Demography

& health

General Register Office of Scotland. Population Pyramids of Scotland. December 2013. Available at:

http://www.gro-scotland.gov.uk/statistics/theme/population/projections/scotland/population-pyramids.html

Main population

within ‘central

belt’

The average number of

people per square

kilometre in Scotland is

68, among the lowest

of the EU countries (i.e.

similar to Ireland and

Bulgaria). There are

huge variations across

the 14 health boards.

• Universal free vaccination at the point of access

• General Practice model of delivery for majority of immunisation programme

– Reimbursement under the global sum paid to General Practices + item of service payment and vaccine cost for selected vaccines (e.g. seasonal influenza vaccine)

• Exceptions offered in the main through secondary school-based programme, e.g.

– Td/IPV, MMR, MenC – school boosters

– HPV programme for adolescent girls

NHS model of immunisation

service delivery across UK

NHS Health Scotland. 2013 National Primary Care Workforce Survey. Available at: http://www.show.scot.nhs.uk

NHS Health Scotland. Your guide to immunisation and vaccines. Available at: http://www.immunisationscotland.org.uk

• All Health issues are devolved from the UK Government to the

Scottish Parliament (a Devolved Administration – DA).

• Health service policy & delivery increasingly different across

UK within each of the three DA’s (Scotland, NI, Wales), e.g.:

– Policy: Minimum pricing for alcohol in Scotland

– Delivery: Health protection within NHS in Scotland c.f. PHE

model in England

• However, whilst Scottish Government set their own

immunisation policy, the risk-based immunisation criteria are

identical to those adopted in England in response to serial

JCVI recommendations made over more than a decade ago

Scottish Immunisation

Programme (SIP)

JCVI, Joint Committee on Vaccination and Immunisation

NHS Health Scotland. Your guide to immunisation and vaccines. Available at: http://www.immunisationscotland.org.uk/

Scottish Immunisation

Programme: Quarterly primary

and booster immunisation uptake

rates by 24 months – reports to 31

December 2013

SIP: Annual primary and booster

immunisation uptake rates by 24

months – reports to 31/12/2014

Source: NHS Scotland Information Services Division.

75

80

85

90

95

100

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Calendar Year

Primary and Booster Immunisation Uptake Rates by 24 Months of Age, by Calendar Year, Scotland

Diphtheria Tetanus Pertussis Polio Hib DTP/Pol/Hib

MenC PCV MMR1 Hib/MenC PCVB

The decrease in MenC uptake at 24 months of age in year ending December 2014 (children born January to December 2012)

is due to the removal of the second dose (given at four months) from the routine schedule from 1 June 2013.

Seasonal flu programme

policy prior to childhood

extension (season 2012/13)

Annually

• All those aged 65 or more

• All those under the age of 65 in clinical risk groups at

increased risk of clinical complication defined by the Chief

Medical Officer (identical CMO groups across the UK)

• All pregnant women (all trimesters)

• All carers

7Chief Medical Officer and Public Health. Season Influenza Vaccination Programme 2012–13. July 2012. SGHD/CMO(2012)6.

Available at: http://www.sehd.scot.nhs.uk/cmo/CMO(2012)06.pdf

Seasonal flu vaccine

uptake 2000/01 to 2012/13

8

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Infl

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Influenza season

65 and over (2000/01 to 2004/5 based on HPS surveillance data, 2005/6 onwards based on GP claimsfor payment)

Under 65s in an at risk group (not available prior to 2004/05; 2004/05 to 2010/11 based on HPSsurveillance data, 2011/12 onwards based on GP claims for payment)

WHO target for seasonal influenza vaccine uptake

Source: Health Protection Scotland (HPS).

JCVI June 2012:

Recommendation for Fluenz

• Extension of seasonal influenza programme to

include all children age 2–17 in annual vaccination

with Live Attenuated Influenza Vaccine (LAIV)

– Implementation over a number of seasons...

– “... does not adversely affect the (immunisation)

programme as a whole”

9JCVI. Positioning statement on the annual influenza vaccination program, July 2012. Available at:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224775/JCVI-statement-on-the-annual-influenza-vaccination-

programme-25-July-2012.pdf

Rationale for decision

• Modelled data: Even with only 30% uptake, Live

Attenuated Intranasal Influenza Vaccine (LAIV)

estimated to be cost effective in children aged 2 to

17 years1,2

• Based upon:

– Direct patient protection

• Vaccine effectiveness of LAIV better than

inactivated vaccines3–7

– Indirect public health benefits

• Reduction in transmission to susceptible groups1

10

1. Baguelin M, et al. Vaccine 2012;30:3459–3462.

2. Baguelin M, et al. PLoS Med 2013;10:e1001527.

3. Belshe RB, et al. N Engl J Med 1998;338:1405–1412.

4. Fleming DM, et al. Pediatr Infect Dis J 2006;25:860–869.

5. Vesikari T, et al. Pediatrics 2006;118:2298–2312.

6. Bracco Neto H, et al. Pediatr Infect Dis J 2009;28:365–371.

7. Tam JS, et al. Pediatr Infect Dis J 2007;26:619–628.

2012/13 Benefit realisation –

flu: Then, now and next?

IMPACT*

(Whole

population)

Measure Prior to

vaccination

programme

No programme

Standard

Programme (to

12/13) (inactivated

vaccine for 65+

and at risk groups)

Programme

extension to

children (add

LAIV for all

2–17 years)

Burden* Annual deaths 900 500 300

Levels of

infection/risk of

transmission

Consultation rates High Moderate Low

Vaccine uptake

(and effectiveness)

Not applicable 75% (30–70%) 75% (50–80%)?

Transmission High Moderate? Low

Health care

utilisation*

Annual

hospitalisations

4,700 2,700 1,600

Annual GP

consultations

100,000 75,000 42,000

*Extrapolation and application to Scotland of Public Health England/London School of Hygiene and Tropical Medicine (PHE/LSH&TM)

assumptions for JCVI June 2012: 1. Uptake limited to 30% in 2–16 years; 2. Modelling includes indirect benefit through “herd-immunity”

protection of adult groups; 3. Census data 2010/11 England & Scotland population estimates as 53 million & 5.3 million, respectively. Societal

burden/health economic costs were also estimated by PHE/LSH&TM.1,2

1. Baguelin M, et al. Vaccine 2012;30:3459–3462; 2. Baguelin M, et al. PLoS Med 2013;10:e1001527.

Recommendation into

UK Government policy

• Recommendation accepted by each DA and policy

implementation followed for year 1 & 2 (seasons 2013/14 and

2014/15) as follows:

• single dose (two doses for < 9years old if naïve & in clinical risk

group)

– Pre-school offer of LAIV

• 2013/14 all UK: vaccination of all 2 & 3 year old children

• 2014/15 all UK: all 2-4 year olds (and 5 year olds not yet in school)

– Children of school age

• Different policy implementation for each DA in year 1 and 2

• Scotland: 2013/14 primary school pilots in all boards (~1/4 primary

school aged children), 2014/15 full primary school roll out.

Chief Medical Officer and Public Health. Important changes to the Scottish immunisation programme in 2013-14 – extension of the

seasonal influenza vaccination programme to children (2–17 years). September 2013. SGHD/CMO(2013)17.

Available at: http://www.sehd.scot.nhs.uk/cmo/CMO(2013)17.pdf

13

Preschool children

• 2013/14 vaccine uptake for 2 & 3 year olds: 50.7%– 2 & 3-year-olds at risk (n=3,669): 66.5%

– 2 & 3-year-olds not at risk (n=116,311): 50.1%

• 2014/15 vaccine uptake for 2 to under 5 year olds (not yet in school): 56.4%– 2 to under 5 year olds at risk (n=5,352): 61.3%

– 2 to under 5 year olds not at risk (n=144,468): 56.2%

13

Source: Health Protection Scotland.

1414

Preschool children

uptake by practice

Source: Health Protection Scotland.

2013/14 - proportion of practices achieving uptake

in 2&3 year olds

2014/15 - proportion of practices achieving uptake in 2 to under 5 year olds not yet in

school≥75% uptake 5.2% 15.0%≥65% uptake 15.9% 34.6%≤40% uptake 19.5% 14.5%

School-age children:

Scottish programme

2013/14 & 2014/15

• 2013/14: Pilot implementation to maximum of 190,000 doses

of LAIV purchased - > offer to ~ ¼ Scottish primary school

children across all NHS boards

– A limited number of whole primary schools AND/OR single year-

group cohorts (e.g. all children in Primary 6 and or Primary 7)

– Nested within these approaches a small number of self-

administration pilots

• 2014/15: Full primary school roll out of LAIV offer

• Contraindication to LAIV – asthma: Severity BTS 4 or above

– TIV offered instead

Source: Scottish Immunisation Programme.BTS, British Thoracic Society

• 2013/14 Primary school pilots

– mean uptake: 67.2%

– range between NHS boards: 60.2 - 76.8%

• 2014/15 Full primary school roll out

– mean uptake: 71.8%

– range between NHS boards: 62.6 – 83.1%

• Good acceptance for offer of LAIV in the primary school setting

• Lower uptake associated with delivery out with school hours (in school setting) or in GP setting

• Self-administration was difficult for 10 to 12 year olds

• Less than 1% wastage in school setting

16

Source: Health Protection Scotland.

Primary school:

2013/14 pilots &

2014/15 full roll out

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• Scottish Index of Multiple Deprivation (SIMD) 2012 quintile

• Increasing uptake most deprived to least deprived (statistically

significant)

• Caveat: By postcode not catchment area

Primary school:

Uptake by SIMD quintile

Source: Health Protection Scotland.

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Proportion of pupils from an ethnic minority

• Decreasing uptake: with increasing proportion of pupils from ethnic minority

Statistically

significant

independent of

SIMD 2012 quintile

Porcine gelatine?

(offer of TIV in

school did not

compensate)

Language?

Caveat: No data on

religion or details of

ethnicity

composition

Primary school:

Uptake by ethnic minority

Source: Health Protection Scotland.

Seasonal flu vaccine

uptake 2000/01 to 2014/15

Source: Health Protection Scotland.

*Data for 2014/15 based on HPS surveillance estimates at week 13

Seasonal programme at

Week 13 compared to prior

seasons

• 65+: 76.3% – in line with previous seasons (13/14: 76.9%; 12/13: 76.8%)

• At risk: 54.0% – lower (denominator inflation) (13/14: 57.5%; 12/13: 56.1%)

• Pregnant at risk: - 65.0% – in line with previous season (13/14: 65.0%; 12/13: 68.7%)

• Pregnant no risk: - 49.5% – higher (13/14: 47.9%; 12/13: 52.9%)

20

Source: Health Protection Scotland.

Interim estimated seasonal flu

vaccine uptake by each devolved

administration

2014/15

1. PHE Weekly National Influenza Report, England, data to 31 January 2015.

2. HPS National Influenza Report, Scotland, data to 29 March 2015.

3. Influenza Weekly Surveillance Bulletin, Northern Ireland, data to 31 March 2015.

Country Age 65 &

over

Age under 65 in

an “at risk group”

Preschool Primary school

aged

England1 72.8% 50.3% 38.5% – 2 years

41.3% – 3 years

32.9% – 4 years

-

Scotland2 76.3% 54.0% 56.4% - 2 to

under 5 year olds

not yet in school

71.8% - all primary

schools

Northern

Ireland3

73.4% 71.8% 54.4% - 2 to 4

year olds

79.7% - all primary

schools

Conclusions & lessons

for next season

• Offer well accepted in schools, less so in preschool &

wastage low (<1%)

• Resources – staff intensive!

• Pilot 13/14 feedback: “Exhausting effort feels like you have

just managed a 12-week outbreak”

• Self – administration not suitable for primary school age

• Consent – consent form optimisation to reduce

administrative burden

• IT development to integrate child health and GP records to

allow call and recall, and facilitate invitation

• Porcine gelatine concerns acknowledged – parent choice:

offer of inactivated injectable vaccine for belief reasons 22

23

Acknowledgements

• Scottish Primary School pupils, parents & staff

• Scottish Local Authority Council Education departments

• National Services Scotland, Health Protection Scotland: Flu, Immunisation, Statistical & IM&T teams

• NHS Boards: School Nursing staff, General Practitioners & their staff, SIP leads

• Scottish Government: Nicola Kerr, Jacqueline Campbell, Dr Nicola Steedman

• Public Health England

• Northern Ireland Department of Health, Social Services and Public Safety

• Welsh Government, Directorate for Public Health 23